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Additional markers to refine the World Health Organization algorithm for diagnosis of pneumonia
A V Castro1, C M Nascimento-Carvalho, F Ney-Oliveria
1Departments of Pediatrics and Radiodiagnosis, Federal University of Bahia and the Emergency Department, Jorge Valente Hospital, Salvador, Bahia, Brazil.
Insights
This study suggests that evaluating a child's history of respiratory distress, fever, chest indrawing, and response to bronchodilators (BD) can help accurately diagnose pneumonia in children with tachypnea, potentially reducing antibiotic overuse.
Area of Science:
- Pediatric Pulmonology
- Infectious Disease Management
- Respiratory Medicine
Background:
- Current World Health Organization (WHO) guidelines recommend antibiotics for all children with tachypnea, leading to overuse.
- Refining diagnostic criteria for pneumonia in children presenting with tachypnea is crucial.
Purpose of the Study:
- To assess the utility of clinical history (previous respiratory distress), physical examination findings (fever, chest indrawing), and bronchodilator (BD) response in diagnosing pneumonia.
- To refine existing guidelines for managing pediatric tachypnea.
Main Methods:
- Prospective study involving 165 children (6-59 months) with cough and tachypnea.
- Chest X-rays interpreted by blinded radiologists; clinical data including fever, chest indrawing, and BD response were recorded.
- Association between persistent tachypnea after BD and pulmonary infiltrates was analyzed.
Main Results:
- Pneumonia was diagnosed in 15.8% of children.
- History of previous respiratory distress was associated with a higher pneumonia diagnosis rate (19.2% vs 5%).
- Persistent tachypnea after BD was significantly associated with pulmonary infiltrates (P=0.02), with a negative predictive value of 87.3% for tachypnea resolution.
Conclusions:
- Combining clinical history, fever, chest indrawing, and BD response can reliably identify pneumonia in children with tachypnea.
- This refined approach may significantly decrease unnecessary antibiotic prescriptions for pediatric respiratory infections.
Introduction:
WHO guidelines for primary care of children with tachypnea indicate that all should receive antibiotics for presumed pneumonia. These guidelines have led to excessive antibiotic use.
Objective:
To examine the value of history of previous respiratory distress, chest indrawing and fever, and response to bronchodilator(BD) to refine these guidelines.
Design:
Prospective study.
Setting:
Urban tertiary care hospital.
Subjects:
Children, between the ages of 6 and 59 months, presenting with cough and tachypnea.
Methods:
182 children were enrolled. Each child had a chest X-ray that was read by two blinded, independent radiologists. Discordance between the two radiologists led to excluding 17 patients. The remaining 165 children were examined for fever and/or chest indrawing, and if they had a history of previous respiratory distress, challenge with a BD. The association of persistent tachypnea after BD and presence of pulmonary infiltrates was recorded.
Results:
The median age was 22 months (mean 25.1 +- 14.5 mo) and 75.8% were aged greater than 1 year. There were 58.8% males. Previous respiratory distress occurred in 65.0% and 79.2% of children aged less than 1 year and 1 year, respectively. Pneumonia was radiologically diagnosed in 26/165 (15.8%). 2/40 (5 %) of children without a history of previous respiratory distress had pneumonia diagnosed. Of 125 children with history of previous respiratory distress, pneumonia was identified in 24 (19.2 %). Persistence of tachypnea after BD was associated with pulmonary infiltrate in 14/24 (58.3%), whereas, tachypnea persisted in 32/101 (31.7%) children without pulmonary infiltrates (P = 0.02). The negative predictive value of resolution of tachypnea was 87.3% (95% CI 77.5 93.4). BD non-response was most useful in children without fever and/or with chest indrawing to indicate pneumonia as the cause of the tachypnea.
Conclusion:
This study indicates that by adding the simple procedures of a history of previous respiratory distress, recording of fever and chest indrawing, and observing the response to bronchodilators, pneumonia can be reliably identified in children presenting with tachypnea and cough. It is probable that this approach to management of children with cough and tachypnea could reduce unnecessary use of antibiotics.
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